Traumatic Disparities:
Surgical Disease and the Great Divergence
June 2014
Vision
Universal access to safe, affordable surgical
and anesthesia care when needed
UHC
Health
Equity
LCoGS Mission
• Raise global surgery within the international
agenda
• Prioritize surgery within national policy
• Improve surgical care delivery
(access/quality/safety)
• All with a goal of achieving our vision
Stakeholders/Audience:
For whom are we responsible?
Stakeholders/Audience:
For whom are we responsible?
People
• Patients
• Community
• Front line caregivers
Vision
Universal access to safe, affordable surgical
and anesthesia care when needed
UHC
Health
Equity
Stakeholders/Audience
Education
and Care
Provider
Organizations
• Academic Med Ctrs
• Professional Colleges
• NGOs
• Facilities
People
• Patients
• Community
• Front line caregivers
Stakeholders/Audience
• Heads of State
• MOH
• MOF
Government
Education
and Care
Provider
Organizations
• Academic Med Ctrs
• Professional Colleges
• NGOs
• Facilities
People
• Patients
• Community
• Front line caregivers
Stakeholders/Audience
• WHO
• World Bank
• USAID
• Clinton/Gates
Foundations
• Academic Med Ctrs
• Professional Colleges
• NGOs
• Facilities
• Heads of State
• MOH
• MOF
International
Agencies
Government
Education
and Care
Provider
Organizations
People
• Patients
• Community
• Front line caregivers
Recommendations
Stakeholders:
n = 37
Government/MOH/MOF
42
Int organizations – WHO, UN, USAID, WB
35
Colleges and Professional Societies
21
Foundations (Gates, etc.)/Big Donors
16
Patients
4
NGO
4
Community Health Workers
1
President and President’s wife
1
Facility Managers, Clinicians
1
NIH/Similar HIC Institutes
1
Recommendations
Sample Suggestions
•
•
•
•
•
WHO/International Organizations
Include universal access to safe surgery in
global health agenda
Collect and share data on metrics identified
Listen to, support LMICs based on local
needs
Pressure gov’ts to improve surgery
Surgery as key component of UHC
Foundations/Big Donors
• Direct money into research, programmatic
support and infrastructure
• Fund programs that build capacity and
focus on health system strengthening
• Create a global surgical fund to support
capability enhancement, system
strengthening, and research
•
•
•
•
•
•
•
•
Government/MOH/MOF
Include access to basic life-saving surgical
care within national health plans.
Invest in human resources necessary for
providing surgical/anesthesia services
Financial protection for poor patients
undergoing surgery
Provide funding for surgical services
Colleges/Professional Societies
Locally based surgical education
Train surgeons in a way that meets
population needs
Advise gov’ts on how to improve existing
facilities
Support task sharing when requested by
LMICs
Traumatic Disparities:
Surgical Disease and the Great Divergence
June 2014
Key Messages
1. Surgery is an indivisible, indispensible component
of a properly functioning health system, UHC and
SDGs, with the ultimate goal of health care equity
– Trauma
– Cancer
2. Investments in surgery are pro growth, cost
effective and have a positive return on investment
3. How can we improve the situation?
4. How can it be paid for?
Key Messages
n = 46
1. Rights/equity (Farmer resolution): 5 billion people do not
have access to safe affordable surgical and anesthesia care
when needed
70%
2. Structure/process (Jim Kim resolution): Surgery is an
indivisible, indispensible component of a properly functioning
health system
85%
3. Governance/management (Eva Hanciles resolution): Huge
gains in surgical care provision are possible with already
existing health care systems by employing proper governance
and management principles and training processes
40%
4. Economic (Yamey/Conteh/Yip resolution): Investments in
surgery are pro growth, cost effective, have a positive ROI
etc…
63%
Key Messages
Other Messages:
•
•
•
•
Access to surgical care should be a universal human right.
Lack of surgical provision leads to an equity issue.
Appropriate training is essential to achieve global surgery.
Start with attention in trauma. When you have a good team to this
attention, I think the surgical system works alone.
• Safe and effective surgical care is the foundation of a functioning,
strengthened health system.
Traumatic Disparities:
Surgical Disease and the Great Divergence
June 2014
Metrics
n = 41
1. Proximity: Percent of population within 2 hours to a facility capable of safe
emergency surgery
71%
2. Timeliness: Emergency surgery performed within 24 hours
73%
3. Workforce: Trained providers per population
83%
4. Throughput: Procedure rate per population
66%
5. Elective to emergency procedure ratio
44%
6. Capacity: Percent of district-level hospitals meeting requirements for safe
surgery
78%
7. Outcomes: Peri-Operative Mortality Rate (all procedures or bellwether)
83%
8. Financial Protection: Percent of population falling into poverty or incurring
catastrophic expenditure due to out-of-pocket healthcare expenditure
73%
9. Mixed: Unmet need for surgical care
63%
10. Strategic Planning: Inclusion of surgery within national or regional health
plans
83%
Metrics
Other Metrics:
• ASA Class
• Metric on blood and oxygen availability (units of blood collected?
availability of blood and oxygen with urban/rural distribution?)
• Is there any measurement of safe referral system?
• Coverage (met need/unmet need)
Requirements for Safe Surgery
n = 31
1. Staff: A trained surgical provider and team
100%
2. Staff: A trained anesthesia provider and team
97%
3. Staff: Postop nursing care, and physiological observations
94%
4. Staff: 24/7 surgical cover to review & assess patients
81%
5. Stuff: Equipment, supplies, consumables, antibiotics and pain meds
100%
6. Stuff: Equipment maintenance
94%
7. Stuff: Sterilization capability
100%
8. Stuff: Screened and cross-matched blood
78%
9. Stuff/Staff protection: Gloves, and the ability to test for HIV
87%
10. Process: Safe surgery checklist *
47%
11. Process: Preoperative risk assessment and operation planning
59%
Requirements for Safe Surgery
Other Metrics:
• Quality and delivery monitoring and feedback mechanism/audit
process
• Basic diagnostics
• Aspirational: Pathology
• Morbidity and mortality
• Minimal lab tests and imagery
• Diagnostics
• Hygiene of the hospital setting
• Ability to refer to a higher level of care via efficient transport system
• Access to support and mentorship (e.g. more senior surgeon)
• Performing surgery within established guidelines
Future Research Agenda
n = 28
Research Areas
Implementation
15
Workforce
14
Quality
12
Barriers to access/care
8
Cost of care delivery
7
Access
7
Burden
6
Other
6
Benchmarking
4
Patient experience
3
Safety
1
28 individual responses
82 research suggestions
Future Research Agenda
Sample Suggestions
Implementation
Quality
• Health system design and operational
• Identify quality issues that cut across all
research
groups of surgery that can be used as a
• What are the optimal methods to deliver
metric and for progress monitoring
surgical care to a broad population quickly • Quality of surgical services: all three
and effectively? Private practice model vs.
aspects of Donabedian Framework
public?
(structure, process, outcomes)
• Research on how to improve systems for
delivery of care and supply chain challenges
Workforce
• Workforce training, distribution and
retention
• Benefits and disadvantages of task shifting
• What are the key incentives to optimize
retention and function of a workforce in a
low-income environment?
Financing
• Financing: What proportion of GDP (both
local and foreign) goes to surgical
spending?
• Capacity development: Impact of
integrative capacity development on
services
Traumatic Disparities:
Surgical Disease and the Great Divergence
June 2014
Items requiring consensus